1. Child Welfare Trauma Training Toolkit Welcome!

2. Child Welfare Trauma Training Toolkit: Module 1 Creating Trauma-Informed Child Welfare Practice: Introduction to the Essential Elements 2

3. Goals of This Training
Educate child welfare professionals about the impact of trauma on the development and behavior of children.
Educate child welfare professionals about when and how to intervene directly in a trauma-sensitive manner and through strategic referrals.
Assure that all children in the child welfare system will have access to timely, quality, and effective trauma- focused interventions and a case planning process that supports resilience in long-term healing and recovery. 3

4. Goals of This Training, cont’d
Assist child welfare workers in achieving the Child and Family Services Review (CFSR) goals of ensuring that all children involved in the nation’s child welfare system achieve a sense of:
Safety
Permanency
Well-being 4

5. Trauma-Informed Child Welfare Practice
The trauma-informed child welfare worker:
Understands the impact of trauma on a child’s behavior, development, relationships, and survival strategies
Can integrate that understanding into planning for the child and family
Understands his or her role in responding to child traumatic stress 5 5

6. Trauma-Informed Child Welfare Practice, cont’d
The Essential Elements:
Are the province of ALL professionals who work in and with the child welfare system
Must, when implemented, take into consideration the child’s developmental level and reflect sensitivity to the child’s family, culture, and language
Help child welfare systems achieve the CFSR goals of safety, permanency and well-being

7. Essential Elements of Trauma-Informed Child Welfare Practice
Maximize the child’s sense of safety.
Assist children in reducing overwhelming emotion.
Help children make new meaning of their trauma history and current experiences.
Address the impact of trauma and subsequent changes in the child’s behavior, development, and relationships.
Coordinate services with other agencies. 7 7

8. Essential Elements of Trauma-Informed Child Welfare Practice
Utilize comprehensive assessment of the child’s trauma experiences and their impact on the child’s development and behavior to guide services.
Support and promote positive and stable relationships in the life of the child.
Provide support and guidance to child’s family and caregivers.
Manage professional and personal stress.

9. Essential Elements Are Consistent With Child Welfare “Best Practices”
Trauma-informed child welfare practice mirrors well- established child welfare priorities.
Implementation does not require more time, but rather a redirection of time.

10. What Makes the Essential Elements “Essential”?
Artwork courtesy of the International Child Art Foundation ( 10

11. 1. Maximize the child’s sense of safety.
Traumatic stress overwhelms a child’s sense of safety and can lead to a variety of survival strategies for coping.
Safety implies both physical safety and psychological safety.
A sense of safety is critical for functioning as well as physical and emotional growth.
While inquiring about emotionally painful and difficult experiences and symptoms, workers must ensure that children are provided a psychologically safe setting. 11

12. 2. Assist children in reducing overwhelming emotion.
Trauma can elicit such intense fear, anger, shame, and helplessness that the child feels overwhelmed.
Overwhelming emotion may delay the development of age- appropriate self-regulation.
Emotions experienced prior to language development maybe be very real for the child but difficult to express or communicate verbally.
Trauma may be “stored” in the body in the form of physical tension or health complaints. 12 12

13. 3. Help children make new meaning of their trauma history and current experiences.
Trauma can lead to serious disruptions in a child’s sense of safety, personal responsibility, and identity.
Distorted connections between thoughts, feelings, and behaviors can disrupt encoding and processing of memory.
Difficulties in communicating about the event may undermine a child’s confidence and social support.
Child welfare workers must help the child feel safe, so he or she can develop a coherent understanding of traumatic experiences. 13 13

14. 4. Address the impact of trauma and subsequent changes in the child’s behavior, development, and relationships.
Traumatic events affect many aspects of the child’s life and can lead to secondary problems (e.g., difficulties in school and relationships, or health-related problems).
These “secondary adversities” may mask symptoms of the underlying traumatic stress and interfere with a child’s recovery from the initial trauma.
Secondary adversities can also lead to changes in the family system and must be addressed prior to or along with trauma-focused interventions. 14 14

15. 5. Coordinate services with other agencies.
Traumatized children and their families are often involved with multiple service systems. Child welfare workers are uniquely able to promote cross-system collaboration.
Service providers should try to develop common protocols and frameworks for documenting trauma history, exchanging information, coordinating assessments, and planning and delivering care.
Collaboration enables all helping professionals to view the child as a whole person, thus preventing potentially competing priorities. 15 15

16. 6. Utilize comprehensive assessment of the child’s trauma experiences and its impact on the child’s development and behavior to guide services.
Thorough assessment can identify a child’s reactions and how his or her behaviors are connected to the traumatic experience.
Thorough assessment can also predict potential risk behaviors and identify interventions that will ultimately reduce risk.
Child welfare workers can use assessment results to determine the need for referral to appropriate trauma-specific mental health care or further comprehensive trauma assessment. 16

17. 7. Support and promote positive and stable relationships in the life of the child.
Separation from an attachment figure, particularly under traumatic and uncertain circumstances, is highly stressful for children.
Familiar and positive figures—teachers, neighbors, siblings, relatives—play an important role in supporting children who have been exposed to trauma.
Minimizing disruptions in relationships and placements and establishing permanency are critical for helping children form and maintain positive attachments. 17

18. 8. Provide support and guidance to the child’s family and caregivers.
Resource families have some of the most challenging roles in the child welfare system.
Resource families must be nurtured and supported so they, in turn, can foster safety and well-being.
Relatives serving as resource families may themselves be dealing with trauma related to the crisis that precipitated child welfare involvement and placement. 18

19. 9. Manage professional and personal stress.
Child welfare is a high-risk profession, and workers may be confronted with danger, threats, or violence.
Child welfare workers may empathize with victims; feelings of helplessness, anger, and fear are common.
Child welfare workers who are parents, or who have histories of childhood trauma, might be at particular risk for experiencing such reactions. 19 19

20. Child Welfare Trauma Training Toolkit: Module 2 What Is Child Traumatic Stress?
Artwork courtesy of the International Child Art Foundation ( 20

21. What Is Child Traumatic Stress?
Child traumatic stress refers to the physical and emotional responses of a child to events that threaten the life or physical integrity of the child or of someone critically important to the child (such as a parent or sibling).
Traumatic events overwhelm a child’s capacity to cope and elicit feelings of terror, powerlessness, and out-of-control physiological arousal. 21

22. What Is Child Traumatic Stress, cont'd
A child’s response to a traumatic event may have a profound effect on his or her perception of self, the world, and the future.
Traumatic events may affect a child’s:
Ability to trust others
Sense of personal safety
Effectiveness in navigating life changes 22

23. Types of Traumatic Stress
Acute trauma is a single traumatic event that is limited in time. Examples include:
Serious accidents
Community violence
Natural disasters (earthquakes, wildfires, floods)
Sudden or violent loss of a loved one
Physical or sexual assault (e.g., being shot or raped)
During an acute event, children go through a variety of feelings, thoughts, and physical reactions that are frightening in and of themselves and contribute to a sense of being overwhelmed. 23

24. Types of Traumatic Stress, cont'd
Chronic trauma refers to the experience of multiple traumatic events.
These may be multiple and varied events—such as a child who is exposed to domestic violence, is involved in a serious car accident, and then becomes a victim of community violence—or longstanding trauma such as physical abuse, neglect, or war.
The effects of chronic trauma are often cumulative, as each event serves to remind the child of prior trauma and reinforce its negative impact.

25. Types of Traumatic Stress, cont'd
Complex trauma describes both exposure to chronic trauma—usually caused by adults entrusted with the child’s care—and the impact of such exposure on the child.
Children who experienced complex trauma have endured multiple interpersonal traumatic events from a very young age.
Complex trauma has profound effects on nearly every aspect of a child’s development and functioning.
Source: Cook et al. (2005). Psychiatr Ann,35(5):

26. Prevalence of Trauma—United States
Each year in the United States, more than 1,400 children— nearly 2 children per 100,000—die of abuse or neglect.
In 2005, 899,000 children were victims of child maltreatment. Of these:
62.8% experienced neglect
16.6% were physically abused
9.3% were sexually abused
7.1% endured emotional or psychological abuse
14.3% experienced other forms of maltreatment (e.g., abandonment, threats of harm, congenital drug addiction)
Source: USDHHS. (2007) Child Maltreatment 2005; Washington, DC: US Gov’t Printing Office. 26

27. U.S. Prevalence, cont'd
One in four children/adolescents experience at least one potentially traumatic event before the age of 16.1
In a 1995 study, 41% of middle school students in urban school systems reported witnessing a stabbing or shooting in the previous year.2
Four out of 10 U.S. children report witnessing violence; 8% report a lifetime prevalence of sexual assault, and 17% report having been physically assaulted.3
1. Costello et al. (2002). J Traum Stress;5(2):
2. Schwab-Stone et al. (1995). J Am Acad Child Adolesc Psychiatry;34(10):
3. Kilpatrick et al. (2003). US Dept. Of Justice. 27

28. Prevalence of Trauma in the Child Welfare Population
A national study of adult “foster care alumni” found higher rates of PTSD (21%) compared with the general population (4.5%). This was higher than rates of PTSD in American war veterans.1
Nearly 80% of abused children face at least one mental health challenge by age 21.2
1. Pecora, et al. (December 10, 2003). Early Results from the Casey National Alumni Study. Available at:
2. ASTHO. (April 2005). Child Maltreatment, Abuse, and Neglect. Available at: 28

29. Prevalence in Child Welfare Population, cont'd
A study of children in foster care revealed that PTSD was diagnosed in 60% of sexually abused children and in 42% of the physically abused children.1
The study also found that 18% of foster children who had not experienced either type of abuse had PTSD,1 possibly as a result of exposure to domestic or community violence.2
1. Dubner et al. (1999). JCCPsych;67(3):
2. Marsenich (March 2002). Evidence-Based Practices in Mental Health Services for Foster Youth. Available at:

30. Prevalence of Trauma—California
Between July 1, 2006 and June 30, 2007, alone, 41,875 children entered California's child welfare-supervised foster care system.
The most common reasons why children were removed and entered child welfare-supervised foster care were:
Neglect: 79.6%
Physical abuse: 11.7%
Sexual abuse: 3.7%
“Other”: 5.9%
Source: Needell et al. (2007). Child Welfare Services Reports for California. Retrieved January 29, 2008, UC-Berkeley Center for Social Services Research ( 30

31. Other Sources of Ongoing Stress
Children in the child welfare system frequently face other sources of ongoing stress that can challenge workers’ ability to intervene. Some of these sources of stress include:
Poverty
Discrimination
Separations from parent/siblings
Frequent moves
School problems
Traumatic grief and loss
Refugee or immigrant experiences 31

32. Variability in Responses to Stressors and Traumatic Events
The impact of a potentially traumatic event is determined by both:
The objective nature of the event
The child’s subjective response to it
Something that is traumatic for one child may not be traumatic for another. 32

33. Variability, cont’d
The impact of a potentially traumatic event depends on several factors, including:
The child’s age and developmental stage
The child’s perception of the danger faced
Whether the child was the victim or a witness
The child’s relationship to the victim or perpetrator
The child’s past experience with trauma
The adversities the child faces following the trauma
The presence/availability of adults who can offer help and protection 33

34. Effects of Trauma Exposure on Children
When trauma is associated with the failure of those who should be protecting and nurturing the child, it has profound and far-reaching effects on nearly every aspect of the child’s life.
Children who have experienced the types of trauma that precipitate entry into the child welfare system typically suffer impairments in many areas of development and functioning, including: 34

35. Effects of Trauma Exposure, cont’d
Attachment. Traumatized children feel that the world is uncertain and unpredictable. They can become socially isolated and can have difficulty relating to and empathizing with others.
Biology. Traumatized children may experience problems with movement and sensation, including hypersensitivity to physical contact and insensitivity to pain. They may exhibit unexplained physical symptoms and increased medical problems.
Mood regulation. Children exposed to trauma can have difficulty regulating their emotions as well as difficulty knowing and describing their feelings and internal states. 35 35

36. Effects of Trauma Exposure, cont’d
Dissociation. Some traumatized children experience a feeling of detachment or depersonalization, as if they are “observing” something happening to them that is unreal.
Behavioral control. Traumatized children can show poor impulse control, self-destructive behavior, and aggression towards others.
Cognition. Traumatized children can have problems focusing on and completing tasks, or planning for and anticipating future events. Some exhibit learning difficulties and problems with language development.
Self-concept. Traumatized children frequently suffer from disturbed body image, low self-esteem, shame, and guilt. 36 36

37. Long-Term Effects of Childhood Trauma
In the absence of more positive coping strategies, children who have experienced trauma may engage in high-risk or destructive coping behaviors.
These behaviors place them at risk for a range of serious mental and physical health problems, including:
Alcoholism
Drug abuse
Depression
Suicide attempts
Sexually transmitted diseases (due to high risk activity with multiple partners)
Heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease
Source: Felitti et al. (1998). Am J Prev Med;14(4): 37 37

38. Childhood Trauma and PTSD
Children who have experienced chronic or complex trauma frequently are diagnosed with PTSD.
According to the American Psychiatric Association,1 PTSD may be diagnosed in children who have:
Experienced, witnessed, or been confronted with one or more events that involved real or threatened death or serious injury to the physical integrity of themselves or others
Responded to these events with intense fear, helplessness, or horror, which may be expressed as disorganized or agitated behavior
Source: American Psychiatric Association. (2000). DSM-IV-TR ( 4th ed.). Washington DC: APA. 38

39. Childhood Trauma and PTSD, cont’d
Key symptoms of PTSD
Reexperiencing the traumatic event (e.g. nightmares, intrusive memories)
Intense psychological or physiological reactions to internal or external cues that symbolize or resemble some aspect of the original trauma
Avoidance of thoughts, feelings, places, and people associated with the trauma
Emotional numbing (e.g. detachment, estrangement, loss of interest in activities)
Increased arousal (e.g. heightened startle response, sleep disorders, irritability)
Source: American Psychiatric Association. (2000). DSM-IV-TR ( 4th ed.). Washington DC: APA.

40. Childhood Trauma and Other Diagnoses
Other common diagnoses for children in the child welfare system include:
Reactive Attachment Disorder
Attention Deficit Hyperactivity Disorder
Oppositional Defiant Disorder
Bipolar Disorder
Conduct Disorder
These diagnoses generally do not capture the full extent of the developmental impact of trauma.
Many children with these diagnoses have a complex trauma history. 40

41. 1. Pynoos et al. (1997). Ann N Y Acad Sci;821:176-193
Trauma and the Brain
Trauma can have serious consequences for the normal development of children’s brains, brain chemistry, and nervous system.
Trauma-induced alterations in biological stress systems can adversely effect brain development, cognitive and academic skills, and language acquisition.
Traumatized children and adolescents display changes in the levels of stress hormones similar to those seen in combat veterans.
These changes may affect the way traumatized children and adolescents respond to future stress in their lives, and may also influence their long-term health.1
1. Pynoos et al. (1997). Ann N Y Acad Sci;821: 41

42. Trauma and the Brain, cont’d
In early childhood, trauma can be associated with reduced size of the cortex.
The cortex is responsible for many complex functions, including memory, attention, perceptual awareness, thinking, language, and consciousness.
Trauma may affect “cross-talk” between the brain’s hemispheres, including parts of the brain governing emotions.
These changes may affect IQ, the ability to regulate emotions, and can lead to increased fearfulness and a reduced sense of safety and protection. 42

43. Trauma and the Brain, cont’d
In school-age children, trauma undermines the development of brain regions that would normally help children:
Manage fears, anxieties, and aggression
Sustain attention for learning and problem solving
Control impulses and manage physical responses to danger, enabling the adolescent to consider and take protective actions
As a result, children may exhibit:
Sleep disturbances
New difficulties with learning
Difficulties in controlling startle reactions
Behavior that shifts between overly fearful and overly aggressive 43

44. Trauma and the Brain, cont’d
In adolescents, trauma can interfere with development of the prefrontal cortex, the region responsible for:
Consideration of the consequences of behavior
Realistic appraisal of danger and safety
Ability to govern behavior and meet longer-term goals
As a result, adolescents who have experienced trauma are at increased risk for:
Reckless and risk-taking behavior
Underachievement and school failure
Poor choices
Aggressive or delinquent activity
Source: American Bar Association. (January 2004). Adolescence, Brain Development and Legal Culpability. Available at: 44

45. The Influence of Culture on Trauma
Social and cultural realities strongly influence children’s risk for—and experience of—trauma.
Children and adolescents from minority backgrounds are at increased risk for trauma exposure and subsequent development of PTSD.
In addition, children’s, families’ and communities’ responses to trauma vary by group. 45

46. The Influence of Culture, cont’d
Many children who enter the child welfare system are from groups that experience:
Discrimination
Negative stereotyping
Poverty
High rates of exposure to community violence
Social and economic marginalization, deprivation, and powerlessness can create barriers to service.
These children can have more severe symptomatology for longer periods of time than their majority group counterparts. 46

47. The Influence of Culture, cont’d
People of different cultural, national, linguistic, spiritual, and ethnic backgrounds may define “trauma” in different ways and use different expressions to describe their experiences.
Child welfare workers’ own backgrounds can influence their perceptions of child traumatic stress and how to intervene.
Assessment of a child’s trauma history should always take into account the cultural background and modes of communication of both the assessor and the family. 47

48. The Influence of Culture, cont’d
Some components of trauma response are common across diverse cultural backgrounds. Other components vary by culture.
Strong cultural identity and community/family connections can contribute to strength and resilience in the face of trauma or they can increase children’s risk for and experience of trauma.
For example, shame is a culturally universal response to child sexual abuse, but the victim’s experience of shame and the way it is handled by others (including family members) varies with culture. 48

49. 1. Fontes. (2005). Child Abuse and Culture. NY: Guilford Press.
The Influence of Culture on Trauma: Shame
Lisa Aronson Fontes1 has described the various components of shame that are affected by culture:
Responsibility for the abuse
Failure to protect
Fate
Damaged goods
Virginity
Predictions of a shameful future
Revictimization
Layers of shame
1. Fontes. (2005). Child Abuse and Culture. NY: Guilford Press. 49

50. What Can a Child Welfare Worker Do?
Understand that social and cultural realities can influence children’s risk, experience, and description of trauma.
Recognize that strong cultural identity can also contribute to resilience of children, their families, and their communities.
Ensure that referrals for therapy are made to therapists who are culturally competent. 50

51. What Can a Child Welfare Worker Do?, cont’d
When arranging out-of-home care, work to locate a kinship/foster/adoptive family that embraces the child’s cultural identity and has the knowledge, skills, and resources to help children.
Consider how your own knowledge, experience, and cultural frame may influence your perceptions of traumatic experiences, their impact, and your choices of intervention strategies.
Utilize resources the family trusts to supplement available services (e.g. bringing in a priest).

52. The Influence of Developmental Stage
Child traumatic stress reactions vary by developmental stage.
Children who have been exposed to trauma expend a great deal of energy responding to, coping with, and coming to terms with the event.
This may reduce children’s capacity to explore the environment and to master age-appropriate developmental tasks.
The longer traumatic stress goes untreated, the farther children tend to stray from appropriate developmental pathways. 52

53. The Influence of Developmental Stage: Young Children
Young children who have experienced trauma may:
Become passive, quiet, and easily alarmed
Become fearful, especially regarding separations and new situations
Experience confusion about assessing threat and finding protection, especially in cases where a parent or caretaker is the aggressor
Regress to recent behaviors (e.g., baby talk, bed-wetting, crying)
Experience strong startle reactions, night terrors, or aggressive outbursts 53

54. The Influence of Developmental Stage: School-Age Children
School-age children with a history of trauma may:
Experience unwanted and intrusive thoughts and images
Become preoccupied with frightening moments from the traumatic experience
Replay the traumatic event in their minds in order to figure out what could have been prevented or how it could have been different
Develop intense, specific new fears linking back to the original danger 54

55. The Influence of Developmental Stage: School-Age Children, cont’d
School-age children may also:
Alternate between shy/withdrawn behavior and unusually aggressive behavior
Become so fearful of recurrence that they avoid previously enjoyable activities
Have thoughts of revenge
Experience sleep disturbances that may interfere with daytime concentration and attention

56. The Influence of Developmental Stage: Adolescents
In response to trauma, adolescents may feel:
That they are weak, strange, childish, or “going crazy”
Embarrassed by their bouts of fear or exaggerated physical responses
That they are unique and alone in their pain and suffering
Anxiety and depression
Intense anger
Low self-esteem and helplessness 56

57. The Influence of Developmental Stage: Adolescents, cont’d
These trauma reactions may in turn lead to:
Aggressive or disruptive behavior
Sleep disturbances masked by late-night studying, television watching, or partying
Drug and alcohol use as a coping mechanism to deal with stress
Over- or under-estimation of danger
Expectations of maltreatment or abandonment
Difficulties with trust
Increased risk of revictimization, especially if the adolescent has lived with chronic or complex trauma 57

58. The Influence of Developmental Stage: Adolescents, Trauma, & Substance Abuse
Adolescents who have experienced trauma may use alcohol or drugs in an attempt to avoid overwhelming emotional and physical responses. In these teens:
Reminders of past trauma may elicit cravings for drugs or alcohol.
Substance abuse further impairs their ability to cope with distressing and traumatic events.
Substance abuse increases the risk of engaging in risky activities that could lead to additional trauma.
Child welfare workers must address the links between trauma and substance abuse and consider referrals for relevant treatment(s). 58

59. The Influence of Developmental Stage: Specific Adolescent Groups
Homeless youth are at greater risk for experiencing trauma than other adolescents.
Many have run away to escape recurrent physical, sexual, and/or emotional abuse
Female homeless teens are particularly at risk for sexual trauma
Special needs adolescents are 2 to 10 times more likely to be abused than their typically developing counterparts.
Lesbian, gay, bisexual, transgender or questioning (LGBTQ) adolescents contend with violence directed at them in response to suspicion about or declaration of their sexual orientation and gender identity 59

60. What Can a Child Welfare Worker Do?
Recognize that exposure to trauma is the rule, not the exception, among children in the child welfare system.
Recognize the signs and symptoms of child traumatic stress and how they vary in different age groups.
Recognize that children’s “bad” behavior is sometimes an adaptation to trauma.
Understand the impact of trauma on different developmental domains. 60

61. What Can a Child Welfare Worker Do? cont’d
Understand the cumulative effect of trauma.
Gather and document psychosocial information regarding all traumas in the child’s life to make better-informed decisions.
Assist parents and caregivers who have secondary adversities and traumatic experiences of their own.
Make a special effort to integrate cultural practices and culturally responsive mental health services.
Identify and build on foster parent and caregiver protective factors.

62. What Can a Child Welfare Worker Do?, cont’d
Recognize that child welfare system interventions have the potential to either exacerbate or decrease the impact of previous traumas.
Lessen the risk of system-induced secondary trauma by serving as a protective and stress-reducing buffer for children:
Develop trust with children through listening, frequent contacts, and honesty in order to mitigate previous traumatic stress.
Avoid repeated interviews, especially about experiences of sexual abuse.
Avoid making professional promises that, if unfulfilled, are likely to increase traumatization. 62

63. Child Welfare Trauma Training Toolkit: Module 3 The Impact of Trauma on Children’s Behavior, Development, and Relationships
Artwork courtesy of the International Child Art Foundation ( 63

64. Essential Elements in Module 3
Maximize the child’s sense of safety.
Assist children in reducing overwhelming emotion.
Help children make new meaning of their trauma history and current experiences. 64

65. Recap: Maximize the child’s sense of safety.
Traumatic stress overwhelms a child’s sense of safety and can lead to a variety of survival strategies for coping.
Safety implies both physical safety and psychological safety.
A sense of safety is critical for functioning as well as physical and emotional growth.
While inquiring about emotionally painful and difficult experiences and symptoms, workers must ensure that children are provided a psychologically safe setting. 65

66. Maximizing Safety: Understanding Children’s Responses
Children who have experienced trauma often exhibit extremely challenging behaviors and reactions.
When we label these behaviors as “good” or “bad,” we forget that children’s behavior is reflective of their experience.
Many of the most challenging behaviors are strategies that in the past may have helped the child survive in the presence of abusive or neglectful caregivers. 66

67. Recap: Assist children in reducing overwhelming emotion.
Trauma can elicit such intense fear, anger, shame, and helplessness that the child feels overwhelmed.
Overwhelming emotion may delay the development of age- appropriate self-regulation.
Emotions experienced prior to language development maybe be very real for the child but difficult to express or communicate verbally.
Trauma may be “stored” in the body in the form of physical tension or health complaints. 67 67

68. Reduce Overwhelming Emotion: Understanding Trauma Reminders
When faced with people, situations, places, or things that remind them of traumatic events, children may experience intense and disturbing feelings tied to the original trauma.
These “trauma reminders” can lead to behaviors that seem out of place, but were appropriate—and perhaps even helpful—at the time of the original traumatic event.
Children who have experienced trauma may face so many trauma reminders in the course of an ordinary day that the whole world seems dangerous and no adult seems deserving of trust. 68

69. Reduce Overwhelming Emotion: Understanding Children’s Responses
When placed in a new, presumably “safe” setting, traumatized children may exhibit behaviors (e.g., aggression, sexualized behaviors) that evoke in their new caregivers some of the same reactions they experienced with other adults (e.g., anger, threats, violence).
Just as traumatized children’s sense of themselves and others is often negative and hopeless, these “reenactment behaviors” can cause the new adults in their lives to feel negative and hopeless about the child. 69

70. Reduce Overwhelming Emotion: Understanding Children’s Responses, cont’d
Children who engage in reenactments are not consciously choosing to repeat painful relationships. The behavior patterns have become ingrained over time because they:
Are familiar and helped the child survive in other relationships
“Prove” the child’s negative beliefs and expectations (a predictable world, even if negative, may feel safer than an unpredictable one)
Help the child vent frustration, anger, and anxiety
Give the child a sense of mastery over the old traumas 70

71. Reduce Overwhelming Emotion: Understanding Children’s Responses, cont’d
Traumatized children may also exhibit:
Over-controlled behavior in an unconscious attempt to counteract feelings of helplessness and impotence
May manifest as difficulty transitioning and changing routines, rigid behavioral patterns, repetitive behaviors, etc.
Under-controlled behavior due to cognitive delays or deficits in planning, organizing, delaying gratification, and exerting control over behavior
May manifest as impulsivity, disorganization, aggression, or other acting-out behaviors 71

72. Reduce Overwhelming Emotion: Understanding Children’s Responses, cont’d
Traumatized children’s maladaptive coping strategies can lead to behaviors that undermine healthy relationships and may disrupt foster placements, including:
Sleeping, eating, elimination problems
High activity level, irritability, acting out
Emotional detachment, unresponsiveness, distance, or numbness
Hypervigilance or feeling that danger is present, even when it isn’t
Increased mental health issues (e.g. depression, anxiety)
An unexpected and exaggerated response when told “no” 72

73. Reduce Overwhelming Emotion: What Child Welfare Workers Can Do
Seek a placement appropriate to the child’s level of distress and risk.
Secure a trauma-focused mental health assessment to identify services and interventions appropriate to the child’s needs.
Share the child’s traumatic experiences and anticipated responses with foster placement providers as appropriate.
Encourage resource parents to provide information if/when new revelations of past traumas emerge. 73

74. Reduce Overwhelming Emotion: What Child Welfare Workers Can Do, cont’d
Empower caregivers about their role of calming and reassuring children.
Educate caregivers about the reasons for, and techniques to manage, children’s emotional outbursts.
Recommend parenting skills training to strengthen caregivers’ ability to handle children’s emotions.
Work with the child to identify and label troubling emotions and stress that the emotions are normal and understandable. 74

75. Recap: Help children make new meaning of their trauma history and current experiences.
Trauma can lead to serious disruptions in a child’s sense of safety, personal responsibility, and identity.
Distorted connections between thoughts, feelings, and behaviors can disrupt encoding and processing of memory.
Difficulties in communicating about the event may undermine child’s confidence and social support.
Child welfare workers can assist traumatized children in developing a coherent understanding of their traumatic experiences. 75 75

76. Make New Meaning of Trauma History: What Child Welfare Workers Can Do
Gather a complete trauma history from parents and child.
As appropriate, provide the child with information about events that led to child welfare involvement in order to help the child correct distortions and reduce self-blame.
Listen to and acknowledge the child’s traumatic experience(s). 76

77. Make New Meaning of Trauma History: What Child Welfare Workers Can Do, cont’d
Support the child in the development of a Life Book (i.e., a book of stories and memories about the child’s life).
Refer the child to evidence-based trauma-focused therapies and provide therapist with complete trauma history.
Require that mental health providers include current caregivers in treatment and educate them about the impact of trauma on child behaviors and behavior management.

78. Child Welfare Trauma Training Toolkit: Module 4 Assessment of a Child’s Trauma Experiences
Artwork courtesy of the International Child Art Foundation ( 78

79. Essential Elements in Module 4
4. Address the impact of trauma and subsequent changes in the child’s behavior, development, and relationships.
5. Coordinate services with other agencies.
6. Utilize comprehensive assessment of the child’s trauma experience and its impact on the child’s development and behavior to guide services. 79

80. Recap: Address the impact of trauma.
Trauma affects many aspects of the child’s life and can lead to secondary problems (e.g., difficulties in school and relationships, or health-related problems).
These “secondary adversities” may mask symptoms of the underlying traumatic stress and interfere with a child’s recovery from the initial trauma.
Secondary adversities can also lead to changes in the family system and must be addressed prior to or along with trauma-focused interventions. 80 80

81. Recap: Coordinate services with other agencies.
Traumatized children and their families are often involved with multiple service systems.
Cross-system collaboration enables all helping professionals to see the child as a whole person, thus preventing potentially competing priorities and messages.
Service providers should try to develop common protocols and frameworks for documenting trauma history, exchanging information, coordinating assessments, and planning and delivering care. 81 81

82. Recap: Utilize comprehensive assessment.
Trauma-specific standardized assessments can identify potential risk behaviors (i.e. danger to self, danger to others) and help determine interventions that will reduce risk.
Thorough assessment can identify a child’s reactions and how his or her behaviors are connected to the traumatic experience.
Assessment results provide valuable information for developing treatment goals with measurable objectives designed to reduce the negative effects of trauma.
Assessment results also can be used to determine the need for referral to trauma-specific mental health care or more detailed trauma assessment. 82

83. The Importance of Trauma Assessment
Not all children who have experienced trauma need trauma-specific intervention.
Some children have amazing natural resilience and are able to use their natural support systems to integrate their traumatic experience.
Ideally, children should be in a stable placement when receiving trauma-informed treatment. However, children should always be referred for necessary treatment regardless of their placement status. 83

84. The Importance of Trauma Assessment, cont'd
Unfortunately, many children in the child welfare system lack natural support systems and need the help of trauma- informed care. Some may meet the clinical criteria for a diagnosis of PTSD.
Many children who do not meet the full criteria for PTSD still suffer significant posttraumatic symptoms that can have a dramatic adverse impact on behavior, judgment, educational performance, and ability to connect with caregivers.
These children need a comprehensive trauma assessment to determine which intervention will be most beneficial. 84

85. The Importance of Trauma Assessment, cont'd
Trauma assessment typically involves conducting a thorough trauma history.
Identify all forms of traumatic events experienced directly or witnessed by the child to determine the best type of treatment for that specific child.
Supplement trauma history with trauma-specific standardized clinical measures to assist in identifying the types and severity of symptoms the child is experiencing. 85

86. What Does Trauma-Informed Assessment and Treatment Look Like?
There are evidence-supported interventions that are appropriate for many children and that share many core components of trauma-informed treatments.
Unfortunately, many therapists who treat traumatized children lack any specialized knowledge or training on trauma and its treatment.
When a child welfare worker has a choice of providers, he or she should select the therapist who is most familiar with the available evidence and has the best training to evaluate and treat the child’s symptoms. 86

87. Examples of Trauma Assessment Measures
UCLA PTSD Index for DSM-IV
Trauma Symptom Checklist for Children (TSCC)
Trauma Symptom Checklist for Young Children (TSCYC)
Child Sexual Behavior Inventory

88. Core Components of Trauma-Informed, Evidence-Based Treatment
Building a strong therapeutic relationship
Psychoeducation about normal responses to trauma
Parent support, conjoint therapy, or parent training
Emotional expression and regulation skills
Anxiety management and relaxation skills
Cognitive processing or reframing 88 88

89. Core Components of Trauma-Informed, Evidence-Based Treatment, cont'd
Construction of a coherent trauma narrative
Strategies that allow exposure to traumatic memories and feelings in tolerable doses so that they can be mastered and integrated into the child’s experience
Personal safety training and other important empowerment activities
Resilience and closure

90. Questions to Ask Therapists/ Agencies That Provide Services
Do you provide trauma-specific or trauma-informed therapy? If so, how do you determine if the child needs a trauma-specific therapy?
How familiar are you with evidence-based treatment models designed and tested for treatment of child trauma-related symptoms?
How do you approach therapy with traumatized children and their families (regardless of whether they indicate or request trauma-informed treatment)?
Describe a typical course of therapy (e.g., can you describe the core components of your treatment approach?). 90

91. Examples of Evidence-Based Treatments
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
Parent-Child Interaction Therapy (PCIT)
Abuse-Focused Cognitive Behavioral Therapy (AF-CBT)
Child-Parent Psychotherapy (CPP)
There are many different evidence-based trauma- focused treatments. A trauma-informed mental health professional should be able to determine which treatment is most appropriate for a given case.

92. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
Originally developed to treat child sexual abuse
An empirically supported intervention based on learning and cognitive theories
Designed to reduce children’s negative emotional and behavioral responses, and to correct maladaptive beliefs and attributions related to the abusive experiences
Aims to provide support and skills to help non-offending parents cope effectively with their own emotional distress and to respond optimally to their abused children
Cohen, et al. (2006). Treating Trauma and Traumatic Grief in Children and Adolescents. New York: Guilford Press.

93. Core Components of TF-CBT
Stress inoculation techniques
Feeling identification
Relaxation, thought stopping, cognitive coping
Cognitive processing (part 1)
The cognitive triangle
Creating a trauma narrative
Cognitive processing (part 2)
Processing the trauma experience
Joint family sessions
Psychoeducation

94. Core Components of Parent-Child Interaction Therapy (PCIT)
Works with the caregiver and child together
Designed to treat children aged 28 years who are exhibiting disruptive behaviors
Use of coaching: caregiver wears hidden earpiece and is prompted by therapist behind a one-way mirror
Average of 1420 weekly sessions focused on relationship enhancement and behavior management
Combines elements from family systems, operant, social learning, and traditional play therapies, as well as early child development theory

95. Utilize Comprehensive Assessment: What Child Welfare Workers Can Do
Gather a full picture of a child’s experiences and trauma history.
Identify immediate needs and concerns in order to prioritize interventions for specific individuals.
Identify and interview individuals or agencies to determine which are knowledgeable about trauma assessment and evidence-based treatments.
Request regular, ongoing assessments (e.g., every three months) regarding the child’s progress and symptoms. 95

96. Utilize Comprehensive Assessment: What Child Welfare Workers Can Do, cont’d
Use tools such as the Child Welfare Trauma Referral Tool to determine whether the child needs mental health treatment and, if so, what type.
Gain a better understanding of the range of programs available in order to make informed choices when referring families to services.
Ensure that families are referred to the most effective programs that the community provides. 96

97. Child Welfare Trauma Referral Tool
Designed to help child welfare workers make more trauma- informed decisions about referral to trauma-specific and general mental health services 97

98. Benefits of Using the Tool
Provides a structure for documenting trauma exposure and severity of traumatic stress reactions
Provides a developmental perspective on the child’s trauma history
Provides a guideline for making referral decisions, rather than arbitrary decision-making
Could be used to facilitate case discussions between caseworkers and supervisors and/or professionals in other systems 98

99. Child Welfare Trauma Training Toolkit: Module 5 Providing Support to the Child, Family, and Caregivers
Artwork courtesy of the International Child Art Foundation ( 99

100. Essential Elements in Module 5
7. Support and promote positive and stable relationships in the life of the child.
8. Provide support and guidance to the child’s family and caregivers.
100

101. Recap: Support and promote positive and stable relationships.
Being separated from an attachment figure, particularly under traumatic and uncertain circumstances, can be very stressful for a child.
In order to form positive attachments and maintain psychological safety, establishing permanency is critical.
Child welfare workers can play a huge role in encouraging and promoting the positive relationships in a child’s life in minimizing the extent to which these relationships are disrupted by constant changes in placement.
101

102. Recap: Provide support and guidance to the child’s family and caregivers.
Children experience their world in the context of family relationships.
Research has demonstrated that support from their caregivers is a key factor influencing children’s psychological recovery from traumatic events.
Resource families have some of the most challenging and emotionally draining roles in the entire child welfare system.
Providing support and guidance to the child’s family and caregivers is a part of federal outcomes (CFSR goals).
102

103. Child Welfare Trauma Training Toolkit: Module 6 Managing Professional and Personal Stress
Artwork courtesy of the International Child Art Foundation (
103

104. Essential Element in Module 6
9. Manage professional and personal stress.
104

105. Recap: Managing stress
Child welfare is a high-risk profession in which workers may be confronted with danger, threats, or violence.
Child welfare workers may empathize with their clients’ experiences; feelings of helplessness, anger, and fear are common.
Child welfare workers who are parents—or who have their own histories of childhood trauma—may be at particular risk for experiencing such reactions.
105
105

106. Impact of Working with Victims of Trauma
Trauma experienced while working in the role of helper has been described as:
Compassion fatigue
Countertransference
Secondary traumatic stress (STS)
Vicarious traumatization
Unlike other forms of job “burnout,” STS is precipitated not by work load and institutional stress but by exposure to clients’ trauma.
STS can disrupt child welfare workers’ lives, feelings, personal relationships, and overall view of the world.
106

107. Managing Stress: What Child Welfare Workers Can Do
Request and expect regular supervision and supportive consultation.
Utilize peer support.
Consider therapy for unresolved trauma, which the child welfare work may be activating.
Practice stress management through meditation, prayer, conscious relaxation, deep breathing, and exercise.
Develop a written plan focused on maintaining work–life balance.
107

108. Child Welfare Trauma Training Toolkit: Module 7 Summary
Artwork courtesy of the International Child Art Foundation (
108

109. Summary
A significant number of children in the child welfare system have been exposed to trauma.
The experience of trauma affects a child’s behavior, development, and relationships.
By understanding how trauma impacts children and adopting a trauma-informed child welfare approach to practice, child welfare workers play a crucial role in mitigating both the short- and long-term effects of trauma.
109

110. Thank you!